GME Changes: Are we in danger of throwing the baby out with the bathwater?

maya.brain headshotGuest Post from
Maya A. Babu, MD (left)
Neurosurgical Resident, Mayo Clinic
Rochester, MN
and
Brian V. Nahed, MD (right)
Assistant Professor of Neurosurgery
Massachusetts General Hospital and Harvard Medical School
Boston, MA

The recent Institute of Medicine (IOM) report heralding potentially major changes in the world of graduate medical education (GME) funding has brought the whole issue of residency training and its finances into the spotlight. One critical aspect of resident training - which resulted, in part, from an earlier IOM report - that is often overlooked is the unintended consequences on physician training resulting from work hour restrictions. Intended to protect residents and patients from fatigue-related medical errors and accidents, there is a growing recognition that these regulations are failing to serve their intended goals.

Duty hour restrictions and polices on fatigue have led to major changes in residency training programs across specialties. Recommendations by the IOM1 and groups such as Public Citizen3 have called for more oversight and restricted work hours to promote patient safety. In response, training sites have expanded the workforce, often with nurse practitioners and physician assistants who, alongside, residents, distribute the increasing demands of clinical paperwork and procedures both in the operating room and at the bedside.

Critics of duty hour restrictions posit that trainees have less clinical exposure during residency and this experience may be skewed (for example, more time in surgery and less in pre- and post-operative care). As a result, fellowships are on the rise in order to gain exposure to varied and specialized patient cases. Fellowships traditionally were reserved for sub-specialties but have now evolved to complete the basic training previously considered part of the residency.  For instance, the American College of Surgeons has pioneered the “Transition to Practice” fellowship, meant to be a year of fellowship in which trainees engage in autonomous operative and clinical decision-making. This provides many of the experiences previously considered an essential part of the chief resident year. Duty hour restrictions, coupled with requirements for attending physicians to participate in the GMEcritical portions of operative cases, significantly limit the independent performance of surgery and decision making by chief residents, necessitating this additional year.6

Potentially compounding the problem is the looming threat of cuts in Medicare GME funding for residency training programs. In 2008, the median GME cost per full-time equivalent (FTE) resident across teaching hospitals was $134,803.7 In neurosurgery, the institutional and departmental costs associated with training neurosurgical residents total approximately $1.2 million per resident over the course of a seven-year residency.8 Given these high costs, in the wake of potential funding cuts, hospitals may consider limiting or replacing residency positions with midlevel practitioners.

In the context of duty hour regulations and the necessary expansion of the clinical workforce to meet our nation’s healthcare needs, budgetary cuts in graduate medical education may undermine residency training as a whole. As training lengthens and physicians become super sub-specialized, careful thought should be given to the future of residency education, especially in the field of neurosurgery.

References

1. Nasca TJ, Day SH, Amis ES, Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 2010;363:e3.
2. STS Urges Debt Negotiations to Include SGR Reform, GME Funding. 2011. (Accessed at http://www.sts.org/news/sts-urges-debt-negotiations-include-sgr-reform-gme-funding)
3. Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician work hours. BMC Med 2010;8:33.
4. Bath J LP. Why we need open simulation to train surgeons in an era of work-hour restrictions. Vascular 2011.
5. Niederee MJ, Knudtson JL, Byrnes MC, Helmer SD, Smith RS. A survey of residents and faculty regarding work hour limitations in surgical training programs. Arch Surg 2003;138:663-9; discussion 9-71.
6. Jeyarajah R, Swanstrom LL, Aye RW, Wexner SD Martinez JM Ross SB, Awad MM, Franklin ME, Arregui ME, Schirmer BD, Minter RM. General Surgery Residency Inadequately Prepares Trainees for Fellowship Results of a Survey of Fellowship Program Directors. Annals of Surgery. 2013;258(3):440-449.
7. Wynn, B. O., R. Smalley, and K. Cordasco. 2013. Does it cost more to train residents or to replace them?A look at the costs and benefits of operating graduate medical education programs. Santa Monica, CA: RAND Corporation. (Accessed at http://www.rand.org/pubs/research_reports/RR324)
8. Ensuring an Adequate Neurosurgical Workforce for the 21st Century 2012. (Accessed at http://www.aans.org/pdf/Legislative/Neurosurgery%20IOM%20GME%20Paper%2012%2019%2012.pdf)

 

Posted in GME, Health, Medicare, Workforce Shortage | Tagged , , , , , |

IOM Report Calls for Sweeping Overhaul of Medical Education Funding

Massachussetts Considers Mandatory Health InsuranceOn July 29, 2014, the Institute of Medicine (IOM) released a report, Graduate Medical Education That Meets the Nation’s Health Needs, which recommends a drastic overhaul of the current graduate medical education (GME) system. The AANS and CNS commend the two-year effort it took to develop this report and are pleased that the IOM committee supported continued Medicare funding of GME. We are, however, disappointed that the IOM failed to adequately address the looming shortage of neurosurgeons. In addition, we are very concerned that the recommendations calling for cuts to GME financing and other changes may jeopardize neurosurgical residency training programs.

As we have reported on Neurosurgery Blog before, experts agree that the country faces a severe physician manpower shortage. Overall, according to the Association of American Medical Colleges, the shortage will approximate 130,600 physicians by the year 2025 - 64,800 specialty physicians and 65,800 primary care physicians. This shortage will become even more acute as health insurance coverage is expanded to an additional 30 million Americans and the baby boomers continue to reach retirement age.

“In the U.S. there are about 3,800 practicing board certified neurosurgeons serving a population of more than 318 million people. As the population ages and more of our citizens face debilitating and life threatening neurological problems such as stroke, degenerative spine disease, Parkinson’s disease and trauma to the brain and spine, this supply-demand mismatch will become even more acute,” said AANS president, Robert E. Harbaugh, MD.”

This shortage has a number of consequences that may limit patient access to neurosurgical care, including:

  • Demand for neurosurgical services will increase by 20 percent over the next decade, far outpacing demand for adult primary care services. As a result, patients are already experiencing significant wait times for neurosurgical care and this is likely to get worse.
  • The concentration of neurosurgeons in metropolitan areas results in twenty-five percent of the U.S. population living in a county without a neurosurgeon.
  • Neurosurgical coverage is essential for effective trauma care and one-quarter of all Americas do not live within 60 minutes of a Level I adult trauma center. Even more do not have a Level I or II pediatric trauma center within their reach.
  • Neurosurgeons are getting older, with forty-four percent of the current neurosurgical workforce over the age of 55. In addition, the time required to become a board certified neurosurgeon is much longer than for primary care and many other specialties - as much as 18 years from the start of medical school to board certification - so replenishing the neurosurgical workforce is no easy task.mal_Page_11

CNS president, Daniel K. Resnick, MD, noted, “An essential solution for increasing physician numbers involves not only increasing medical-student class size and the number of medical schools, but also increasing the number of funded residency positions, which Congress can do by lifting the cap on the number of federally supported residency training positions.” Dr. Resnick added, “Unfortunately, the IOM has gone in the opposite direction by recommending cuts in GME funding, which will likely exacerbate the predicted physician shortage.”

An appropriate supply of well‐educated and trained physicians is essential to ensure access to quality healthcare services for all Americans. Organized neurosurgery is committed to ensuring that our patients have access to high-quality neurosurgical care and we stand ready to help develop policies to avert the impending physician workforce crisis.

Posted in Medicare |

Right on the Money

Guest Post from Deborah L. Benzil, MD, FACS, FAANS
Member, AANS Board of Directors
Chair, AANS/CNS Communications and Public Relations Committee
MKMG
Columbia University Medical Center
Mt Kisco, New York

debThere is not much about healthcare policy on which everyone agrees; however one irrefutable fact acknowledged by most is that U.S. healthcare costs are rising, outstripping inflation, and thus exerting pressure on many aspects of the economy. In 2012, healthcare costs topped $2.8 trillion – and this trend shows no end in sight! Not only do these costs act as a drag on our economy, but Americans feel the pain directly, since over the last decade insurance premiums for the average family of four have risen more than 100 percent.

Beyond this basic fact, however, a fierce debate rages. Much of the recent focus on containing healthcare costs seems directed primarily at physicians. The debacle for holding down physician expenditures, known as the Medicare “sustainable growth rate,” is just one component of this process. (Little mentioned, and entirely forgotten, is the fact that the SGR was the only cost containment process left in place from the Balanced Budget Act of 1997, while others that impacted other healthcare providers, including hospitals and nursing homes, were lobbied away). Physician services represent roughly 20 percent of each healthcare dollar, compared with more than 30 percent for hospital costs. Of the 20 percent for physicians, only a portion becomes actual physician take-home pay, as most of this goes towards practice overhead, which is high (and rising).

National Health Expenditures 2014 (projected) (2)

Elizabeth Rosenthal, in her excellent and insightful news analysis, “Medicine’s Top Earners Are Not the M.D.’s” discusses another closely held secret within our current healthcare system: the exorbitantly high administrative costs (in hospitals, health insurance, and healthcare systems) presently being paid. The article notes that Mark T. Bertolini, thecroppedRosenthal_400x400 chief executive of Aetna, earned a salary just under $1 million, but his total annual compensation was in excess of $35 million! Based on data from the Medical Group Management Association, he earned more than 160 primary care physicians and 90 specialists combined! And he is just one executive of one insurance carrier.

So returning to what we all agree on — healthcare costs are rising too quickly. However, curtailing those costs should not break the back of those (the physicians) that provide the critical diagnostic and therapeutic interventions that help patients. Neurosurgeons provide accessible, compassionate care for patients with some of the most devastating medical conditions. We are there for our patients. We will work with those voices of reason to help ensure value in healthcare delivery and appropriate costs. But let us be RIGHT ON THE MONEY by understanding:

  1. Physicians were the only sector of healthcare whose costs were essentially capped by the Balanced Budget Act of 1997.
  2. Physician services represent a small fraction (less than 20 percent) of all healthcare dollars, the slowest growing component of healthcare costs.
  3. Administrators salaries are today’s TOP EARNERS in medicine, while providing no direct healthcare services and little or no direct benefits to patients.
Posted in Access to Care, Guest Post, Health, Healthcare Costs | Tagged , , |